Should Vaccination Be a Personal Choice?

By Brenda Goodman, MA
WebMD Health News

Reviewed by Hansa D. Bhargava, MD

Jan. 29, 2015 -- As a measles outbreak linked to Disneyland and Disney California Adventure Park continues to spread, a backlash against parents who refuse or delay vaccination for their children has risen to a fever pitch.

More and more pediatricians say they are "firing" patients who decide not to vaccinate. On social media, angry parents engage in heated debates about the decision not to vaccinate. One columnist suggested parents who don't vaccinate their kids should go to jail. And at least one well-known infectious disease expert called for states to make it tougher for parents to opt out of the shots.

"It's not just about you. You're part of a social order. You've got to make your own contribution to it. You can't opt out. This is a stronger statement than I've ever made to the media. But I think we should become increasingly intolerant of parents opting out," says William Schaffner, MD. He's a professor of preventive medicine at Vanderbilt University in Nashville, TN.

There's good reason to be angry. Diseases like whooping cough and measles, which had been all but wiped out in this country, are making a comeback. In 2014, 644 people caught measles in the U.S., the most in more than two decades, according to the CDC. With nearly 60 cases in seven states connected to the two Disney parks so far this year, 2015 might be on pace to be even worse.

"It's only January and we've already had a very large number of measles cases. This worries me," says Anne Schuchat, MD. She's the director of the CDC's National Center for Immunization and Respiratory Diseases. She spoke at a press briefing on the outbreak and urged children and adults to get vaccinated.

Experts say preventable diseases like these are gaining a foothold again because many parents have taken advantage of laws in 48 states that allow families to skip or delay the shots for religious or personal reasons.

"Ten to 20 percent delay the shots. One to 2 percent choose not to vaccinate at all," says Paul Offit, MD, director of the Vaccine Education Center at The Children's Hospital of Philadelphia.

That wouldn't be so bad if they were evenly distributed across the U.S., putting an unvaccinated kid here or there. But people who decide to go unprotected tend to cluster in groups.

A Tale of Two States

An investigation by the The Hollywood Reporter found that in some affluent neighborhoods around Los Angeles, more than 60% of preschoolers are unvaccinated, giving the area a rate of vaccination comparable to South Sudan. California logged more than 60 measles cases last year, and has 79 just in the first month of this year, with most connected to Disneyland.

"These upper-middle-class kids are taken on trips abroad, and that's where they pick up the measles," Schaffner says. They bring it back to the U.S. before symptoms have appeared, "and they spread it among their peers."

In Mississippi, on the other hand, which has one of the strictest vaccine laws in the nation -- parents can send their kids to school unvaccinated only for medical reasons -- just 17 exemptions were granted for kindergartners in the entire state for the 2013-14 school year, according to the CDC. As a result, while the rest of the country was on the alert for a disease so contagious that it infects more than 90% of people who are exposed, Mississippi was clear. There were no cases of measles reported in the state last year or for the past several years.

To infectious disease experts, the lesson is obvious.

"At its best, measles is an absolutely miserable week. At its worst, it's deadly. Why should we tolerate this? Why should we let parents opt out? Sorry. We've decided to go on the green and stop on red. And when anybody violates that, it causes chaos and damage, and not just to themselves," Schaffner says.

He says advances in medical treatment have allowed more children with diseases like cancer or asthma to attend school.

"Many can't be vaccinated or don't respond well to vaccines. How do we protect them? All of us get vaccinated and surround them," he says. Protecting an individual by immunizing everyone around them is a concept called "herd immunity."

Some states are starting to make it tougher for parents to opt out. Washington, California, Oregon, and Michigan have all recently added a requirement that parents get some kind of education about vaccines before they can refuse the shots for school-aged children. Legislators in Minnesota will introduce a similar bill in the state this month, says Diane Peterson, an associate director at the Immunization Action Coalition.

One Mother's Story

To many parents, though, the decision to vaccinate isn't so black-and-white.

"When you're on the side where you have the herd immunity around you, you don't think, 'Oh, I'm going to be impacting all these people,' because really, outbreaks are rare. The logic doesn't always kick in," says Karen Moore, a mother in Virginia who delayed her children's shots because of concerns over vaccine side effects.

"You're not weighing the risk correctly because you haven't seen the disease."

It took several bad flu seasons and a case of whooping cough, or pertussis, to convince Moore and her two teenage kids that they needed to be up to date on their shots.


Whooping Cough (Pertussis) Symptoms, Vaccine Facts See Slideshow

She says her partner, who was diagnosed with pertussis at the age of 53, coughed for 90 days. He hacked so violently that he would pass out and hit his head.

"And I said, 'I've had enough,' you know. 'This is stupid,'" she says. "The possibility of babies getting it is just horrific."

"I've made a full shift, but I think people shouldn't be judgmental to people who aren't there yet. It doesn't make any sense if you've never considered not vaccinating. People just think it's ignorance," she says.

Fears Influence Some Parents' Decisions

In many ways Moore's story is typical of people who decide to not vaccinate.

Back in the late 1990s, when her oldest child was born, there was scary new research -- which has since been discredited -- that linked the measles, mumps, and rubella (MMR) vaccine to autism. The midwives who delivered her baby were very skeptical about the shots, so she put them off.

Later, fears about autism were replaced by the idea -- espoused by pediatrician Robert Sears, MD, and embraced by the anti-vaccine movement -- that maybe kids were getting too many shots. The worry was that so many injections spaced closely together might overwhelm their developing immune systems and lead to lifelong problems like allergies and asthma.

And infants can seem a bit like little pincushions. At a minimum, a baby who gets vaccinated on the schedule recommended by the CDC can expect to get more than 20 shots for 12 different diseases by the time they are 15 months old.

But experts say the idea that too many shots delivered at the same time might be dangerous is a myth.

"You certainly don't overwhelm the immune system by giving vaccines when recommended, and there's everything to be lost. You increase the period of time when children are susceptible," Offit says.

He points out that very quickly after birth, trillions of bacteria will colonize a baby's body.

Each bacterium has between 2,000 and 6,000 parts that the immune system will learn to recognize and respond to.

"If you add up all the immunological components of vaccines today it's probably about 160. It's nothing. It's not just figuratively a drop in the ocean, it's literally a drop in the ocean of what you encounter and manage every day," he says.

Other experts point out that vaccines, when given according the schedule set by the CDC, are timed to take over when natural immunity wears off.

In the case of the MMR, which contains live but weakened virus, babies can get their first dose at 12 months, because they still have antibodies to measles passed down from their mother. If the vaccine was given sooner, those antibodies would kill the virus, rendering the vaccine ineffective. If the vaccine was given much later, a child is left unprotected.

"The alternative vaccination schedules are out there. I've seen them on web sites. Parents have printed them out and showed them to me," says Matthew B. Laurens, MD. He's an associate professor of pediatrics at the University of Maryland School of Medicine.

Laurens and other experts say there's no proof that the alternate schedules are effective or safe. They aren't based on science. But many parents follow them anyway, saying they make instinctive sense.

Education vs. 'Coercion'

Over the years, Moore, who has a college degree and has done some graduate work, would pick and choose if and when to get her children immunized. When her son got vaccines, it was only after she pored over ingredient lists and had a thorough discussion with her pediatrician about the risks and benefits of each injection. In Virginia, where she lives, she was able to get an exemption for her daughter on religious grounds.

"I really wanted people to talk to me about it. I wanted to be respected and not be called an idiot," she says.

She says it was finding a doctor who would listen to her and discuss her fears that helped change her thinking.

"I think education should be mandatory, but I don't think coercion should be."

Other experts agree with her.

"The argument, the way it is right now, doesn't help anybody," says Bernice Hausman, PhD, who studies medical rhetoric at Virginia Tech in Blacksburg, VA. She's traced the history of vaccine fears and says the tone of the current debate over vaccines is so militant that it's created a stalemate.

"Let's take, for example, the idea that doctors should fire patients who won't vaccinate or won't vaccinate their children. What that does is create problems for families who have concerns about vaccinations in finding adequate medical care. It alienates them from the medical system," she says.

"You have pro-vaccination people saying, 'You're stupid, you don't understand. You're endangering everyone.' You have people on the other side saying, 'We're trying to use medical evidence as best we can to make decisions for our families that fit our values.' How is that un-American?"

"In a medical world where shared decision-making is more and more the norm, why is this the one area where people shouldn't have a choice?"

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SOURCES: William Schaffner, MD, professor of preventive medicine, Vanderbilt University Nashville, Tenn. CDC: "Measles Cases and Outbreaks", accessed January 29, 2015. The Hollywood Reporter: "Hollywood's Vaccine Wars: L.A.'s "Entitled" Westsiders Behind City's Epidemic." California Department of Public Health, Measles Outbreak Update, Jan. 22, 2015. CDC: "Morbidity and Mortality Weekly Report, October 17, 2014." Diane Peterson, associate director of immunization projects, Immunization Action Coalition. Karen Moore, Virginia, mother who delayed vaccination. Paul Offit, MD, director, the vaccine education center, The Children's Hospital of Philadelphia, Philadelphia, PA. Matthew Laurens, MD, associate professor of Pediatrics, The Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD. Bernice Hausman, PhD, professor of English and the Humanities, Virginia Tech, Blacksburg, VA.

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